Appeals Documentation Tips

Impacting both Commercial and Medicaid Expansion

Did you know?
Blue Cross Blue Shield of North Dakota (BCBSND) is currently seeing an increased number of appeals with little or no documentation for both our Commercial and Medicaid Expansion lines of business. We would like to remind our provider community of some important tips that were published in a previous HealthCare News article Reminders: Important Appeal Tips and the importance of documentation to avoid delays and denials.

Providers must include supporting documentation. Supporting documentation of an appeal is the key part of BCBSND Clinical teams review process to make an appeal decision. When documentation is not complete or does not tell the story this causes additional work for both providers and BCBSND, adding to delays and denials.

Not sure what to document?
Here are some additional tips for documentation needs for appeals:

• BCBSND will return an appeal with no documentation or lack of documentation to providers and require a resubmission of a new appeal.
  • The new appeal must be reissued within the appeals time limits.
    • BCBSND will not consider the first submission date due to lack of documentation.

Commercial Appeal submission time limits

• The appeal must be received one hundred eighty (180) days from the adverse determination for both pre and/or post service.
• The appeal must be received within one hundred eighty (180) days of the date BCBSND notifies the health care provider or member of the precertification result and/or the appeal must be received within 180 days of the date BCBSND notifies the health care provider or member of the claim for benefits determination

Medicaid Expansion Appeal submission time limits

• The appeal must be received sixty (60) days from the adverse determination for both pre and/or post service.
• The appeal must be received within sixty (60) days of the date BCBSND notifies the health care provider or member of the precertification result and/or the appeal must be received within 60 days of the date BCBSND notifies the health care provider or member of the claim for benefits determination.
• Providers should send only minimally necessary documentation to support the appeal
  • Providers sending excessive amounts of information that does not relate to their appeal also causes additional delays
• BCBSND Medical Policies will often define when additional supporting documentation is required to assist in the determination of medical necessity.
  • Example: Ambulance Services: Air and Water Transportation
    • Ambulance providers are required to retain documentation on file supporting all ambulance services (i.e., trip sheets).
    • More than one individual may be transported, (e.g., from the scene of a traffic accident).
    • When multiple individual transports are reported, the statement "multiple individuals" and the number transported must be documented.

We appreciate the provider community's work to help improve our appeals process.

Questions?
Refer to our appeals and documentation sections of our Provider Manual and Medicaid Expansion Provider Manual or in need of further assistance, contact the appropriate Provider Service Center:

• Commercial: 1-800-368-2312
• Medicaid Expansion: 1-833-777-5779